The effect on plasma corticosteroid levels of the short term topical application of clobetasol propionate

Thirty-four patients with skin diseases which necessitated treatment with potent topical steroids at a hospital clinic were studied. All the patients received clobetasol propionate ointment (Dermovate) for a period of 2 weeks and sixteen of the patients continued with their treatment for 4 weeks, during which time their plasma corticosteroid levels were measured. Thirty patients had normal levels throughout the whole period of study (≥ 6 μg/100 ml) and five patients showed a depressed level at some stage during the investigation. Of six patients who were using a large amount of clobetasol ointment (more than 100 g/week) and who had a significant proportion of their body affected by disease (20-80%), two had lowered plasma corticosteroid levels and in four there was no evidence of adrenal suppression.     

Dermatitis herpetiformis exacerbated by indomethacin

Thirteen adults with dermatitis herpetiformis (DH) controlled by dapsone or sulphamethoxypyridazine were given indomethacin or placebo in a double-blind cross-over study. In nine of the thirteen patients the rash and pruritus of DH were exacerbated more by indomethacin than by placebo. Dapsone and sulphamethoxypyridazine requirements were increased during the indomethacin period. The involvement of lipoxygenase products in the pathogenesis of the DH skin lesions is postulated.     

Dermatitis herpetiformis: an evaluation of diagnostic criteria

Forty-two patients in whom a clinical diagnosis of dermatitis herpetiformis (DH) had been, made, were studied. All patients had a small intestinal biopsy, a biopsy of uninvolved skin for detection of the presence of IgA deposits by immunofluorescence, serum and red cell folate estimations and examination of the serum for anti-reticulin antibody. The response of the skin eruption to dapsone was noted. Thirty patients had biopsies of skin lesions for routine histological examination. IgA deposits were found in the uninvolved skin of thirty-five of the forty-two patients. Evidence of an enteropathy was found in thirty-four of those thirty-five patients. Of the seven patients who did not have IgA in the uninvolved skin, only one showed evidence of enteropathy, which was slight, and this patient was shown subsequently to have pemphigus and not DH. Of the thirty biopsies of skin lesions, only five showed all the features usually considered to be characteristic of DH. And-reticulin antibody was found in eight patients, and in all of these IgA was present in the uninvolved skin. Low red cell folate levels were found in eleven patients (all of whom had an enteropathy and IgA in the uninvolved skin). Low serum folate levels were found in thirty-four patients, thirty-one of whom had IgA deposits in the uninvolved skin and an enteropathy; in the other three patients who did not have IgA deposits or an enteropathy, all were on dapsone and this may have accounted for the abnormal result. In forty-one of the forty-two patients the rash was dapsone responsive. The patient who showed no response to dapsone had no IgA in the uninvolved skin and no evidence of enteropathy. Follow-up showed that of the seven patients with no IgA in the skin, one had pemphigus, and in three the rash eventually cleared spontaneously and the patients no longer required treatment. There was no evidence of spontaneous remissions in the patients with IgA in the uninvolvcd skin. It would appear that the presence of IgA deposits in the uninvolved skin is part of the syndrome of DH and that the diagnosis should not be made unless these deposits are found.     

Comparison of immunoglobulin and complement deposition in multiple biopsies from the uninvolved skin in dermatitis herpetiformis

The distribution of immunoglobulins and C3 component of complement (C3) in the skin of twenty-four patients with dermatitis herpetiformis was studied. Skin biopsies were taken from three sites, the extensor surface of the elbow, the flexor surface of the forearm and from the thigh. Twenty-two (90%) patients showed variation in deposits of immunoglobulins and C3 at the three sites. IgA was present in all patients, but differed in quantities deposited at the three sites in nineteen (80%) patients. Similar variation between sites was observed with IgG, IgM and C3. There was variation within three biopsies, IgA being absent from some sections and present in others. Three patients had a continuous pattern of IgA deposition. One had both continuous and papillary deposits within a single section. There was no difference in the incidence or quantity of immunoglobulin and C3 between the elbow, forearm and thigh. There was observed to be a diminution in quantity of IgA and incidence of C3 in patients taking a gluten-free diet. Deposition of IgA, IgM, IgG and C3 is not uniform throughout the skin and conclusions drawn from the quantity of immunoglobulin and C3 in a single biopsy may not be reliable.     

Pacing Threshold Spikes Months and Years After Implant

To determine patterns of variation in chronic pacing thresholds, we made 4,942 threshold measurements in 257 patients with 312 leads, at times from implant to 295 months (median 17 months) including 1,053 determinations in 46 children < 12 years old. Motivation was late sudden death in two single-ventricle pacemaker-dependent children with multiple possible death causes. At stimulus duration 0.5 ± 0.04 msec, mean of the thresholds, measured 1 month or more after implant, was 1.3 ± 0.66 volts (V) for endocardial electrodes and 2.8 ± 1.39 V for epicardially applied electrodes. Highest mean thresholds were in the 6 to 12-year-old age group. In 34 leads studied at implant, again within a month and for at least three years thereafter, time of maximum threshold occurred after one month in 59%, independent of lead type or patient age. Of 107 leads with five or more measurements after 3 months use, gradual increase in threshold continued after 3 months in 24%. An additional 21% had at least one threshold that exceeded the post-three-months individual patient lead mean by three standard deviations. Most striking was the occurrence of transient several-volt increases and decreases in threshold as late as 8 years after lead implantation in at least three children. These temporary changes were detected initially transtelephonically by the vario method of threshold measurement. They occurred during minor illnesses such as summer colds, yet similar illnesses also occurred without threshold elevation. We suggest further study of pacing threshold variations in highly pacemaker-dependent children whose cardiac anatomy makes use of epicardial electrodes necessary.     

Congenital Chylothorax and Persistent Pulmonary Hypertension of the Neonate

ABSTRACT. In this case of congenital chylothorax, an associated persistent pulmonary hypertension was a severe complication which has not hitherto been described. Recurrence of the chylothorax with the introduction of regular formula is also reported.     

Disc Electrophoresis Study of Serum Proteins from Patients with Multiple Myeloma and Macroglobulinemia

Sera from 31 patients with plasma cell myeloma and seven with macroglobulinemia were analyzed by the disc electrophoresis method (Ornsteinand David).

Of the 31 myeloma cases, 24 were found to have a single component. In theremaining cases, in spite of apparent homogeneity in paper electrophoresis,several abnormal components were seen.

Ultracentrifugal studies revealed that the heterogeneous myeloma components are a group of globulins with a sedimentation rate between 7S and19S. Some of the latter components could be easily dissociated by sulfhydrylliberating compounds.

Comparison of the results with those obtained by paper and immunoelectrophoresis demonstrated that all the heterogeneous proteins were fast globulinsof the _2A type.

The possible significance of the heterogeneous myloma proteins is discussed.

Submitted on November 26, 1962 Accepted on April 3, 1963     

Pemphigus controlled by sulphapyridine

A patient with an II-year history of a generalized blistering eruption is described. The eruption was completely controlled within I week of taking sulphapyridine and recurred within 4 days of with-drawal of this drug. On account of these observations a diagnosis of dermatitis herpetiformis was made. Histological, immunological (and small intestinal) studies now show that this patient had pemphigus.